Many Patients Unhappy With H.M.O.'s

By MILT FREUDENHEIM

Published: August 18, 1993

A nationwide study of more than 17,000 patients has found widespread dissatisfaction with health maintenance organizations, adding fuel to a growing national debate over the merits of managed health care.

Patients were more likely to be satisfied with the explanations of their treatments from doctors working in their own offices or in small single-specialty groups than from H.M.O.'s, the researchers said. The patients also said that independent doctors had showed more interest in their well-being.

And independent doctors were easier to reach by telephone and more apt to schedule office appointments on short notice than were doctors in large medical groups and H.M.O.'s, the study found.

By contrast, people enrolled in health maintenance organizations or treated by large multispecialty practices were more likely to complain of long hours in the waiting room, followed by too short a visit with the doctor.

To slow the growth of health-care costs, managed-care organizations typically restrict payments unless care is approved in advance by a designated primary-care doctor. What Critics Say

Critics say many organizations economize by making it difficult to get a doctor's appointment, shuttling patients from one doctor to another and giving the doctors incentives to see too many patients in too little time.

"Patients bounce around in these systems," said John E. Ware Jr., a senior researcher at the New England Medical Center. "It's the dark side of managed care."

In the study, which was financed by the Federal Government, researchers at Johns Hopkins University and the New England Medical Center analyzed how 17,671 patients rated their treatment in small offices, large multispecialty medical practices and H.M.O.'s with salaried doctors.

The study, reported in today's issue of the Journal of the American Medical Association, was based on interviews conducted in 1986 in 367 medical offices in Boston, Chicago and Los Angeles and updated in 1990. The findings had not been previously reported.

The researchers asked patients to rate services from excellent to poor and then compared the percentage of excellent ratings that patients gave to their overall care, as well as to particular kinds of service.

Don White, a spokesman for the H.M.O. industry, said his group's ratings would have been much higher if responses of "very good" and "good" had been included. But Mr. Ware said that patients were generally reluctant to criticize medical services, so ratings of less than excellent were misleading. Politically Hot Subject

"The study's findings are particularly important in light of President Clinton's health care reform efforts," said Dr. Haya R. Rubin, director of quality of care research at the Johns Hopkins medical school, who was the lead author of the article. "To the extent that managed care encourages doctors and hospitals to be in very big groups, that may be less desirable from a patient's point of view."

The Clinton Administration is drafting plans for a medical system that would offer incentives to enroll in health maintenance organizations and similar prepaid medical plans, which typically limit the use of hospitals and specialists.

The President said on Monday in a speech to the National Governors Association that the system should contain significant new incentives to prevent overuse of health care services.

Dr. Rubin said patients' views of their doctors could often affect their health. "Studies show the more satisfied you are, the more likely you are to come back to that doctor," she said.

Dr. Joseph Painter, a Houston oncologist who is president of the American Medical Association, agreed that "a patient who is happy with the physician, both individually and professionally, will carry out the doctor's order, whether it is exercising, losing weight or taking pills."

But Mr. White, the industry spokesman, said, "The deck was stacked against H.M.O.'s" in the three-city study. The Group Health Association of America in Washington said the authors should have asked about features that H.M.O. members appreciate, like low out-of-pocket costs and fewer medical forms to fill out.

The association said a number of other studies had found that H.M.O. members were as satisfied with the managed care organizations as others were with traditional insurance. Other Studies

But Mr. Ware said the authors and the experts who reviewed the study for the medical association journal were not aware of any comparable studies that contradicted the three-city study.

Indeed, a 1992 Government-financed study of elderly Medicare patients also reported that members were less likely to rate their health plans as excellent as to how well the care was explained, how long they had to wait both for appointments and in the office, and how thorough the treatment was.

Several large employers said some of their people had similar complaints. "I'm not terribly surprised by their findings," said Gary Yeaw, director of benefit services at Allied-Signal Inc., where 48,000 of the 70,000 American employees are in managed-care programs, including 5,000 in H.M.O.'s with staffs of salaried physicians.

He said that when given a choice, this type of organization attracted younger people with large families who like the one-stop shopping. Employees who do not like these model H.M.O.'s often transfer to other types of health plans.

While they urge their employees to join H.M.O.'s because of the cost savings, a number of larger employers, including Allied-Signal and the Xerox Corporation, are prodding the organizations to improve patient services. "H.M.O.'s have to do better," said Helen Darling, a Xerox benefits executive. "You have to push them." Varyied Ratings

Not all H.M.O.'s are alike, of course. Dr. Rubin noted that one of the three organizations in the survey received excellent ratings from 55 percent of the patients, compared with 49 percent and 37 percent for the other two. The overall excellent ratings in the three cities for independent doctors in small offices were between 62 percent and 69 percent. For small offices working with H.M.O.'s, the range was 51 percent to 66 percent.

"Patients seem to like to receive their care in doctors' offices, whether they are members of H.M.O.'s or not," said Dr. Steve Zatz, head of a quality of care unit of U.S. Healthcare, based in Bluebell, Pa., a large H.M.O. whose members are cared for by independent doctors.

His organization is one of a growing number of large managed-care organizations that say they are always analyzing their performance and polling patients, and trying to improve. Dr. Don M. Nielsen, who is in charge of quality at Kaiser Permanente, the big, nonprofit national H.M.O. based in Oakland, Calif., said Kaiser had also "worked very hard to improve access and meet our members' expectations."

Dr. John Ludden, medical director of the Harvard Community Health Plan, based in Brookline, Mass., added, "Large organizations can become impersonal quite easily." He said his organization had a training program for doctors to show them "how to produce satisfaction for patients."